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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 1868 E . Hazelton Ave . , Stockton , California 95205 <br /> Telephone : ( 209 ) 468-3420 Fax : ( 209 ) 468- 3433 <br /> APPLICATION FOR UNDERGROUND STORAGE TANK <br /> RETROFIT OR PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE , INDICATE PERMIT TYPE BELOW: <br /> ❑ TANK RETROFIT ❑ PIPING REPAIR/RETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br /> F EPA Site # Project Contact & Telephone # MERLIN BOWEN 925 . 551 . 7555 <br /> C Facility Name DART CONTAINER CORPORATION Phone # 209 . 933 , 8088 <br /> I <br /> L Address 1400 E . VICTOR AVENUE , LODI , CA 95240 <br /> T Cross Street N . GUILA AVENUE <br /> Y Owner/Operator DART CONTAINER CORPORATION Phone # 209 . 933 . 7555 <br /> C Contractor Name Gettler Ryan Inc . Phone # 925 . 551 . 7555 <br /> O <br /> N Contractor Address 6805 Sierra Court , Suite G , SUITE G CA Lic # 220793 Class A/B/C61 = D40/CIC <br /> T <br /> R <br /> A Insurer TRAVELERS PROP & CASUALTY CO . OF AMERICA Work Comp # UB7K6098961826G <br /> C <br /> r ICC Technician 's Name TIM PERRY Expiration Date 3/22/2020 <br /> o <br /> R ICC Installer's Name TIM PERRY Expiration Date 3/22/2020 <br /> Tank system work area Tank Size Chemicals Stored Currently Date UST <br /> (i.e. 87 piping sump, 91 leak detector, UDC V2, etc.) Installed <br /> T DROP TUBES 10 , 000 DIESEL UNKNOWN <br /> A SPILL BUCKETS <br /> N <br /> K <br /> P ❑ Approved Approved with conditions ElDisapproved <br /> L See Attachment With Conditions ) <br /> A <br /> N Plan Reviewers Name ��i� Date 9 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES , STATE LAWS , AND RULES AND REGULATIONS OF SAN <br /> JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THISPEW1IT IS ISSUED , I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br /> WORKER'S COMPENSATION LAWS OF CALIFORNIA." NTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING : "I CERTIFY <br /> THAT IN THE PERFORMANCE OF THE WORK FO H THIS PERMIT IS ISSUED , I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br /> OF CALIFORNIA ." <br /> Applicant's Signature TitIeAGENT FOR OWNER Date 3/ 19/2019 <br /> BILLING INFORMATION : <br /> Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank . If <br /> the party designated below is different than the permit applicant, e. g . property owner, the party must acknowledge this <br /> responsibility for the billing by signature and date below. <br /> NAME Liddy McKenzie TITLE Project Manager PHONE # 925 . 551 . 7555 <br /> ADDRESS 6805 SIERRA CT , SUITE G , DU , 94568 <br /> SIGNATURE DATE <br /> EH230038 ( revised 07-17-2014) <br /> 2 <br />